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OMS Peripheral > Hand/Wrist > Flashcards

Hand/Wrist Flashcards

1
Q

What type of joint is the distal radioulnar joint?

A

Pivot joint - responsible for pronation and supination

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2
Q

What closes the distal radioulnar joint?

A

A triangular fibrocartilaginous disc

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3
Q

What does the triangular fibrocartilaginous disc articulate with?

A

Horizontal plane: apex attaches to the ulnar styloid and base to the lower edge of the ulnar notch of the radius.

It articulates with the lunate when the wrist is in ulnar deviation

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4
Q

What is the triangular fibrocartilaginous disc’s role?

A
  • Adds to the stability of the joint
  • Articular cushion for the ulnar side of the carpus
  • Absorbing compression/traction/shearing forces
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5
Q

What are the two rows of carpal bones on the palmar aspect (radial to ulnar side)

“Some Lovers Try Positions That They Can’t Handle”

A 
Scaphoid
Lunate
Tiquetral
Pisiform
Trapezium
Trapezoid
Capitate
Hamate
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6
Q

What type of joint is the wrist joint proper?

A

Biaxial, ellipsoid joint between the distal end of the radius and the articular disc, and the proximal row of carpal bones.

The joint also includes the metacarpal joint which has mobility and stability.

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7
Q

What are the movements of the wrist?

A

1- Flexion (85 degrees)
2- Extension (85 degrees)
3- Ulnar deviation (45 degrees)
4- Radial deviation (15 degrees)

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8
Q

What stabilises the synovial membrane/capsule of the wrist?

A

1- Two collateral ligaments - they go from the appropriate styloid to the carpal bones on the medial (triquetral) and lateral side (scaphoid) side of the carpus.

2- A meniscus projects into the joint from the ulnar collateral ligament

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9
Q

What type of joints are the metacarpalphalangeal joints?

A

Ellipsoid

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10
Q

What type of joints are the interphalangeal joints?

A

Hinge

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11
Q

What support the dorsal surfaces of the MCP and IP joints?

A

1- Palmar ligaments
2- Collateral ligaments
3- Extensor tendons
4- Digital expansions

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12
Q

What makes the flexor tendons more at risk of “trigger finger”?

A

They have fibrous sheaths with thickened areas known as ‘pulleys’ - these may provide a restriction

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13
Q

What is the flexor retinaculum attached to?

“STOP”

A

Laterally - Scaphoid tuberosity and ridge of the Trapezium

Medially - Pisiform and hook Of hamate

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14
Q

What structures run through the carpal tunnel?

A

1- Flexor digitorum superficialis (4)
2- Flexor digitorum profundus (4)
3- Flexor pollicis longus (1)
4 - Median nerve

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15
Q

What type of joint is the trapeziofirst-metacarpal joint?

A

Saddle

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16
Q

How do the tendons of the flexor digitorum superficialis lie?

A

They all lie within the same sheath but the tendons for the 3rd and 4th fingers lie superficially to the 5th and 2nd fingers’

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17
Q

What does the flexor carpi ulnaris create in the hand?

A

Tunnel of Guyon - the pisohamate ligament (which is a slip off the flexor carpi ulnaris) converts the space between the pisiform and hamate into a tunnel which houses the ulnar vessels and nerves.

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18
Q

Which muscles form the lateral border of the snuff box? Why could they cause friction?

A

Abductor pollicis longus and Extensor pollicis brevis

They become tendinous half way up the forearm and superficial in the lower forearm where they cross the tendons of the extensor carpi radiali brevis and longus - source of friction.

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19
Q

What makes up the medial border of the snuff box?

A

Extensor pollicis longus

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20
Q

What does the abductor pollicis longus do?

A

1- Abducts the thumb

2- Radially deviates the wrist

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21
Q

Which muscles abducts the fingers?

“DAB”

A

Dorsal interossei

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22
Q

Which muscles adduct the fingers?

“PAD”

A

Palmar interossei

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23
Q

Where is the inferior radioulnar joint line?

A

It lies approx 1.5 cm laterally from the ulnar styloid, best felt on the dorsum of the hand

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24
Q

Which is the largest carpal bone? How big is it?

A

The capitate is the largest carpal bone, roughly the size of the patient’s thumb nail.

It is peg shaped (wider dorsally)

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25
Q

What does the capitate articulate with?

A

Laterally - Trapezoid
Medially - Hamate
Distally - Third metacarpal
Proximally - Concavity formed by the lunate and scaphoid

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26
Q

Where do extensor carpi radialis brevis and longus insert?

A

Longus - base of the second metacarpal

Brevis - base of the third metacarpal

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27
Q

What is the site and spread of pain like in the hand?

A

Usually well localised with little spread

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28
Q

What possible conditions could occur after a fall with an outstretched hand?

A

1- Fractured scaphoid
2- Subluxation of the capitate or lunate bones
3- Traumatic arthritis with soft tissue swelling and contusion

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29
Q

What are de Quervain’s and carpal tunnel possibly associated with?

A

More proximal lesions, such as nerve entrapment or lesions at the cervical spine

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30
Q

What does tendinopathy most often result from?

A

1- Frequent overstretching

2- Unaccustomed activity

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31
Q

What are the two most common types of stresses to cause an overuse syndrome?

A

1- Abnormal shear stresses

2- Tensional overloading

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32
Q

What is the most common injury to the thumb?

A

Hyperextension injury to the thumb, usually from sports. It produces traumatic arthritis in either the trapeziofirst-metacarpal joint or the metacarpophalangeal joint

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33
Q

What is the difference between adult RA and juvenile chronic RA?

A

Adult RA is bilateral while the juvenile form is not.

34
Q

Which joints are most affected with primary degenerative OA?

A

1- Trapeziofirstmetacarpal joints

2- Distal interphalangeal joints

35
Q

What is Heberden’s node?

A

Bony swelling of the distal interphalangeal joint, characteristic of primary degenerative OA

36
Q

What is characteristic of Dupuytren’s contracture?

A

It is a deformity caused by the contracture of the palmar fascia, causing flexion of mainly the 4th and 5th fingers

37
Q

Where would muscle waisting be seen with median nerve/carpal tunnel/cervical nerve root involvement?

A

There would be flattening of the thenar muscles and the thumb would move back in line with the fingers

38
Q

Where would muscle waisting be seen with ulnar nerve/lower cervical nerve root involvement?

A

The hypothenar eminence would waist, and if the intrinsic muscles were involved then a claw hand would develop

39
Q

Where would muscle waisting be seen with radial nerve involvement?

A

The wrist extensors would be affected causing a drop wrist

40
Q

Which passive movement to the trapeziofirstmetacarpal joint is always painful with OA?

A

Extension and adduction

41
Q

What is the treatment for OA of the hand and wrist?

A

1- Injection

2- Grade B mobilisation

42
Q

How to differentiate OA and de Quervain’s of the trapeziofirst-metacarpal joint?

A

Compression/grind test: If it reproduces pain then it is positive for OA

43
Q

How to choose treatment of the trapeziofirst-metacarpal joint?

A

1- If there is still an elastic end feel on testing the limited movement –> friction, stretches and distraction
2- If there is a hard end feel –> injection

44
Q

How does the lunate sublux?

A

It may displace anteriorly when the wrist is forced into extension.

45
Q

What are the findings for a subluxed capitate?

A

Hx:

  • Fall on outstretched hand or repeated wrist extension with compression
  • Pain and limited movement
  • Bump dorsally

Objective:

  • Passive extension is painful and limited by a bony block
  • Full passive flexion but painful at end of range
  • Bony bump might become prominent dorsally on flexion
46
Q

What is the treatment for a subluxed capitate?

A
  • Grade A under strong traction

- The ligaments around the capitate may also be frictioned if pain persists after relocation

47
Q

What are the findings for sprained collateral wrist ligaments?

A

Hx:

  • Traumatic overstretching
  • Repetitive microtrauma due to overuse
  • May be associated to RA or OA
  • Localised pain

Objective:

  • Stretching the ligament passively to the opposite side causes pain
  • Ligament tender under palpation
48
Q

What is the treatment for sprained collateral wrist ligaments?

A
  • Injection

- Friction

49
Q

Factors effecting carpal tunnel - intrinsic and external

A

Intrinsic:

  • Inflammation and swelling of any structure within the tunnel
  • Reduction of the size of the tunnel itself: tenosynovitis, hypothyroidism, diabetes, pregnancy, obesity, RA, acromegaly

External:

  • Trauma
  • Pressure
  • Repetitive occupational or leisure activities
  • Repeated griping or squeezing
  • Excessive vibration from heavy machinery
  • Keyboard use
  • Knitting
  • Etc.
50
Q

Who is most at risk of carpal tunnel?

A

Women between 40 - 60 (peaking in the late 50s)

51
Q

What are the findings with carpal tunnel?

A

Hx:

  • Complaints of aching, burning, tingling, numbness, paraesthesia in the radial three and a half digits on the palmar surface
  • 70% experience night numbness
  • 40% pain radiating proximally into the forearm with simultaneous paraesthesia of the fingers
  • May wake up at night due to the symptoms and gain relief by shaking or rubbing the hands
  • May complain of loss of dexterity and clumsiness of the hands

Objective:

  • Waisting of the thenar eminence
  • Positive Tinel’s sign and Phalen’s test
52
Q

How long does it take for a Phalen’s test to be positive?

A

If symptoms are recreated in under 2 minutes it is positive. If no symptoms by 3 minutes then the test can be regarded negative.

53
Q

What is the treatment of carpal tunnel?

A

1- Advice to avoid repetitive actions
2- Injection
3- Wrist splint to wear at night
4- Surgical release of the flexor retinaculum

54
Q

What are the findings for fibrocartilage tears and meniscal lesions/ intra-articular complex?

A

Hx:

  • Trauma
  • Central or radial tears are most common
  • Pain and clicking on the ulnar side of the wrist

Objective:

  • Clicking on pronation and supination
  • Passive ulnar deviation may recreate the pain
  • Point tenderness may be felt just distal to the ulnar styloid
  • To confirm the diagnosis: wrist placed in extension and ulnar deviation + axial compression to the ulnar side of the wrist during circumduction
55
Q

What is the treatment for a mechanical lesion of the intra-articular complex of the wrist?

A

1- Strong distraction (to reduce possible displacement)

2- Arthroscopy and reduction

56
Q

What is incidence of trigger finger (per finger)?

A
  • 35% involve the flexor pollicis longus tendon

- 50% involve the middle or ring finger flexor tendons

57
Q

What is the treatment for trigger fingers?

A
  • Injection
58
Q

What are the most common lesions found at the wrist and what are their causes? (2)

A

1- Tendinopathy at the teno-osseous junction of a tendon
2- Tenosynovitis affecting the tendon in its sheath, as it runs under either flexor or extensor retinaculum

These can happen either:

  • single unit
  • repetitive strain injury or work related upper limb disorder (more complex syndrome)

Causes:
- Overuse (most likely)

59
Q

What is the treatment for tendinopathy at the teno-osseous junction?

A
  • Injection

- Friction

60
Q

What is the treatment for tenosynovitis?

A
  • Injection
  • Friction (applied with the tendon on stretch to restore the glide of the tendon within its sheath)
  • +/- thumb splint
61
Q

What is de Quervain’s?

A

It is tenosynovitis of the abductor pollicis longus and extensor pollicis brevis in the first extensor compartment at the wrist

62
Q

What further complications could occur in de Quervain’s?

A

1- de Quervain’s stenosing tenosynovitis: when the shared sheath is thickened due to scarring associated with chronic inflammation
2- A ganglion can also be associated with the condition

63
Q

Which persons are most affected by de Quervain’s?

A

Women

64
Q

What is the onset of de Quervain’s?

A
  • Trauma (occasionally)

- Repetitive occupational or leisure activities

65
Q

What are the findings for de Quervain’s?

A

Hx:

  • Pain felt on the radial side with point tenderness over the radial styloid
  • Pain is aggravated by ulnar deviation, forced flexion/adduction of the thumb, wringing movements of the hand especially into ulnar deviation
  • Crepitus may be audible

Objective:

  • A local, thickened swelling on palpation
  • Pain on resisted thumb abduction and extension
  • Passive movements of the thumb are painful
  • Axial grind test of the trapeziofirst-metacarpal joint should be negative
  • Positive Finklestein’s (thumb in flexion and hand placed in ulnar deviation = Pain)
66
Q

What is intersection syndrome or oarsman’s wrist?

A

It is tenosynovitis at a point where four tendons intersect and cause friction under the extensor retinaculum (4 cms proximal to the wrist) –> at the musculotendinous junction of the lower forearm

The tendons:
1- Abductor pollicis longus
2- Extensor pollicis brevis
3- Extensor carpi radialis longus
4- Extensor carpi radialis brevis

Has been attributed to bursitis

67
Q

What are the findings with intersection syndrome?

A

Hx:

  • Overuse
  • Acute pain
  • Symptoms of inflammation (heat, inflammation, swelling, redness, disturbed function)

Objective:
- Crepitation of the muscle bellies can be heard but pain makes objective testing very difficult

68
Q

What is the treatment for intersection syndrome?

A
  • Protect, ice, rest
  • Gentle friction for analgesic function then 6 good sweeps to produce movement
  • Advice: relative rest where functional movements may continue within pain free range until it is pain free on resisted testing
69
Q

What is the second most common tenosynovitis of the wrist?

A

Extensor carpi ulnaris tendinopathy/tenosynovitis

70
Q

What is the most common cause of extensor carpi ulnaris tenosynovitis?

A
  • Repetitive overuse, sometimes occurring in the non-dominant hand (e.g. tennis player using double handed backhand)
  • Direct trauma: may cause subluxation of the tendon from the groove between the head of the ulna and the styloid.
71
Q

What are the findings with extensor carpi ulnaris tenosynovitis?

A

Hx:

- Pain and clicking on the ulnar side of the wrist

72
Q

How do you differentiate extensor carpi ulnaris tenosynovitis from a triangular fibrocartilage or meniscal lesion?

A

When the extended wrist is actively taken from radial deviation to ulnar deviation, the subluxation of the extensor carpi ulnaris tendon can be seen

73
Q

What is the treatment for extensor carpi ulnaris tenosynovitis?

A
  • Injection

- Friction with the tendon on stretch

74
Q

What is the main cause of extensor carpi radialis longus and brevis tendinopathy?

A
  • Repetitive overuse

- Bony metacarpal protuberance or boss

75
Q

Where does tendinopathy of the extensor radialis longus/brevis occur?

A

At the teno-osseous junction

76
Q

What are the objective findings for extensor radialis longus/brevis tendinopathy

A

Pain on resisted wrist extension and radial deviation

77
Q

What is the treatment for extensor radialis longus/brevis tendinopathy?

A
  • Injection

- Friction (on stretch)

78
Q

Where can tendinopathy occur with the flexor carpi ulnaris?

A

Insertional tendinopathy at the proximal and distal teno-osseous junctions at the pisiform

79
Q

What is the treatment for flexor carpi ulnaris tendinopathy?

A
  • Injection (though be careful of the ulnar nerve which is lateral to the tendon)
  • Friction to either the distal (distal to the pisiform) or proximal (down onto the pisiform) end of the teno-osseous junction
80
Q

What persons are most affected by dorsal interossei lesions?

A

Musicians and tennis players

81
Q

What are the findings for dorsal interossei lesions?

A

Hx:

  • Vague pain over the metacarpophalangeal joint or between metacarpals
  • Pain is exacerbated by repeated gripping

Objective:
- Pain on resisted finger abduction of the appropriate finger

82
Q

What is the treatment for dorsal interossei lesions?

A
  • Friction (parallel to the metacarpal and apply pressure towards the metacarpal)

OMS Peripheral (8 decks)

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